Monday, July 11, 2005

Will primary care become a team sport ?Thoughts on The Society of General Internal Medicine's task force on the Future of General Internal Medicine

The Society of General Internal Medicine organized a task force to "redefine the domain of general internal medicine" The final report was released on Sept.20, 2003 and is available in full text on line. In the introductory section the authors state " Chaos may be the word that best characterizes American medicine for many patients and doctors today"
Having said that, the stage is set to make suggestions as that implies something has to be done. One of their recommendations was that " general internists should usually work in teams" I found this intriguing as I had never really worked on a team nor do any of my colleagues do so now except perhaps in some metaphorical or virtual sense. One could count the internist and his rounding partner(s) and the receptionist and the nurse and the various folks in the medical field who from time to time play a role as being on a team but that seems a stretch. Because of this emphasis the task force recommends changes in the residency training program to include leadership training to lead these teams.
The task force report does not present a strong case for the team concept. The closest to that I could find in the paper was the following. Although the authors admit that for some types of patients specialists may provide better care than the generalist they quote one paper suggesting that generalists working with specialists appear to" provide better care". While this may be true in some settings it need not be so generally and at most this data point points in the direction of the benefit derived from cooperation not necessarily from formal teams.
No other footnotes are referenced in the context of teams but one citation dealing with the importance of focusing on what patients want did discuss the value of teams.That citation is:
Dr. Dana Safran from the Health institute at Tufts-New England Medical Center writing in the Feb. 4 2003 Annals of Internal Medicine. One of the elements Safran believes are essentiall to secure primary care is " adapting of the current functioning of primary care team so that they become visible, meaningful and valued from the patient's perspective."
The only argument for this presented by Safran provides indirect evidence ( ie evidence which if believed requires an inference on the part of the "trier of fact" to accept the matter asserted- to use the words of a law book-). It involves comparison of patient satisfaction in a closed model HMO versus an open model practice. A characteristic of the former is the place of "invisible" teams and emphasis on having the patients seen sooner rather than necessarily having the patient seen by the same physician each time. Patient seem to prefer the open model. They would rather see their doctor than be seen sooner by someone they do not know.
Rather than concluding teams are not well received, Dr. Safran interprets these data to mean that teams need to be made visible and the patients educated to their role and then presumably better care will result. Safran quotes three articles said to provide " considerable empirical evidence" that links the performance of care teams to improved health care and decreased costs. Two of the studies involve intensive care medicine and post op care which seem not relevant to primary care. The third article deal with newborn health care delivery. There is also some data indicating that rapid response teams in hospitals may be worthwhile. However,I see little data available indicating the value of teams in primary care,certainty much less than I would think is needed to state that "visible" primary teams are essential .
I am aware that "teams" is one of the politically medically correct terms to which to pledging allegiance seems required. A body no less august that the Institute of Medicine has placed its imprimatur on it. IOM lists "working as part of interdisciplinary teams" as one of the five core areas which medical professionals should ensure proficiency. In the era of evidence based medicine, I do not know what energizes this team concept movement but it seems to be something other that than sound evidence. No one opposes cooperation and prima donnas are not held in high esteem, but I think a patient in the middle of the night wants to call Dr. Jones not the "health care team".
I worry that with the emphasis on teams, team work , team player etc that we may loose in the shuffle or at least not adequately emphasize a physician's prime directive "The individual physician is responsible for the individual patient and the patient's welfare". The incorporation of that concept into a person's makeup is a major part of the transformation of a lay person into a physician.More and more it seems disabusing physicians of that archaic concpet is a prominent and recurring theme in the speeches and writings of medical academia and the leadership of various professional organizations.

1 comment:

It's been said that the generation now entering medical school--Generation Y, the ones with the most disposable income of any youth in history--are also incapable of original thought. They have been dubbed "groupthinkers." Unlike my Generation X cohorts, who are jaded and blase--but never conforming--the denizens of Generation Y live to listen to Muzak and embody the Benetton rainbow of a smiling workplace, where everyone is loved and every opinion has merit. Not only does this make things less scary and innovative; it also spreads around liability and blame.

Managing doctors has long been tantamount to herding cats, and I can't help but think that this "team" approach is just another glossy word to use in some corporate mission statement. At the end of the day, it's one doc per order. And when I'm the attending, I'll listen to the radiologist and make my own decisions.

Medicine can't be one man, one vote. The attending of the primary service is the general, and everyone else is infantry. Of course, in military management, the person with the most expertise in any given area carries the most weight in his area of decision making, but there can be only one battle plan.

Now what service is primary? Well, that always makes for interesting hospital politics.